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Assistant Manager at Fertilizer Mixing Facility Dies When Pinned Under Overturned 1972 Tractor Without a ROPS
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2014/05/01
[PDF-566.90 KB]
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Description:In the winter of 2013, a male fertilizer mixing facility assistant manager in his 30s died when his 1972 Case 580B Construction King tractor with a front end loader overturned after sliding down the walls of a drainage ditch. The tractor was not equipped with a roll over protection structure (ROPS) and seat belt. The decedent had unsuccessfully attempted to remove a 12-foot section of the rail of a railroad on the south side of the facility with the tractor bucket. The facility's General Manager determined that another method should be used to remove the rail. The decedent was in the process of backing the tractor away so he could move it to another area. The tractor length, including the bucket was approximately 15 feet. The decedent backed the tractor approximately 20 feet. The ground was snow covered. The back wheels of the tractor slipped into an approximate nine-foot-deep ravine with an unmarked edge. As the tractor was sliding down the ditch, he attempted to drive the tractor forward, but the tractor continued to slide into the ravine. When the front wheels of the tractor reached the edge of the ravine, the tractor overturned to the rear. The decedent was pinned against the ravine bank by the tractor seat. A ROPS was an optional piece of equipment when the tractor was built in 1972. Factors that contributed to this incident include: 1) Tractor not equipped with a ROPS and seatbelt; 2) Edge of embankment not marked; 3) Frozen, snow-covered ground; 4) Two-wheel drive tractor was not equipped with chains for traction. RECOMMENDATIONS: 1. Retrofit older tractors with properly designed and manufactured ROPS and seat belt. If a ROPS is not available, consider replacing the older tractor with a tractor which can be equipped with or already has a ROPS. 2. To alert workers, mark edges of an embankment with visual cues, such as elevated, reflective stakes, orange fencing, or permanent barriers when in a traveled work area to alert workers. 3. Tractor operators should use extreme caution when using tractors on or near sloped terrain, ditches, or embankments. 4. Management should develop and implement a written safety and health program and train employees about the program. 5. Install tire chains on two-wheel drive tractors during winter to aid traction.
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Pages in Document:1-9
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NIOSHTIC Number:20045683
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NTIS Accession Number:PB2015-102784
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Citation:Morgantown, WV: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, FACE 13MI009, 2014 May; :1-9
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Federal Fiscal Year:2014
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Performing Organization:Michigan State University
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Peer Reviewed:False
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Start Date:2005/07/01
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End Date:2026/06/30
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Resource Number:FACE-13MI009
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